Indian Institute of Technology Guwahati Application Form for Admission to Institute Post Doctoral Fellowship (IPDF) for Aushadhi Open Innovation Programme

PHOTOGRAPH 1. Name : __________________________________________________________

Date of Birth:

Affix Recent Passport Size Photo

Age :

Address for Communication:

Permanent Address :

Pin Code:

Pin Code:

Phone No:

Phone No:

Mobile No:

Mobile No:

Email:

Email:

2. Details of University/ Institution Studied (Bachelor's level and above) Sl.No

University/College/Board

Degree obtained Year of (with discipline) completion

% Marks/ CGPA /CPI

Class/Division

Honours/Major Subjects

3. Whether any degree was obtained through Correspondence course / distance education mode (Tick the relevant)

YES

NO

(If yes give the details)

………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………

4. Professional Experience (Teaching/ Research / Industrial) if any: (Please use separate sheets, if necessary) Name of Organization

Designation

Period From

Nature of Work To

5. Research Publication details: (Please enclosed a list of your research publications in a separate sheet) Total Number of Publications in

International

National

Referred Journals Referred Conference Proceedings

6. PhD thesis related information: (a) Title

: __________________________________________________________ __________________________________________________________

(b) Date of Submission of Thesis: (c) Date of Ph.D. Defense Exam: Enclose a copy of short abstract of the Ph.D. thesis work.

7. Your understanding about Aushadhi Open Innovation Programme and your proposed research work under this programme during the fellowship: (Detailed work plan may be attached)

9. Personal Information: (a)

(h)

Father's / Spouse’s Name

(b)

Father's /Spouse’s occupation

(c)

Place of Birth

(d)

Mother tongue

(e)

Nationality

(f)

Gender(Male/Female):

Whether the applicant is employed ?

YES

NO

:

(If yes, the application should be submitted through proper channel or NOC from the employer to be submitted at the time of interview)

(j)

Whether SC/ST/OBC(NCL):

YES

NO

(If yes, enclose the relevant copy of the certificate)

Name of the caste / Sub-caste………………………………….

(k)

Whether Person : YES

NO

With Disability (PwD)

(g)

Martial Status

Married

Unmarried

(If yes, enclose the relevant copy of the certificate briefly describe its nature)

DECLARATION I hereby declare that I have carefully read the instructions and particulars supplied to me and that the entries made in this application form are correct to the best of my knowledge and belief. I understand that association (active or passive) with any unlawful organization is forbidden. If selected, I promise to abide by the rules and discipline of the Institute. I note that the decision of the Institute is final in regard to selection for admission and assignment to a particular Department and field of study. The Institute shall have the right to expel me from the Institute at any time after my admission, provided it is satisfied that I was admitted on false particulars furnished by me or my antecedents prove that my continuance in the Institute is not desirable. I agree that I shall abide by the decision of the Institute, which shall be final. I hereby further declare that, I have not completed five years since completion of my Ph.D.

Place : Date : Signature of Applicant ……………………………………………………………………………………………………………………………………………………… Check List : 1) The filled up application form should have the following enclosures: a)

A two page write-up on the intended Research work under Aushadhi Open Innovation Programme at IITG.

b)

No objection certificate / relief certificate from the present employer (if currently employed)

c)

Photocopies of the Degree certificates.

d)

Photocopies of two best journal papers.

2) The applications should be sent (through proper channels in case of the employed candidates) to the following address on or before August 21, 2017(Monday). On the envelope, write superscribed as “Application for IPDF-Aushadhi)”.

Academic Registrar Academic Affairs Section Indian Institute of Technology Guwahati, Guwahati-781039, Assam, India

INSTITUTE POST DOCTORAL FELLOWSHIP (IPDF) AT IIT GUWAHATI NO OBJECTION CERTIFICATE FROM THE EMPLOYER (To be submitted along with Application)

The application of …..…………..………………………………………. working as……………………………….. ..……….………………………………………………in……….…………………………………..……………………………………… ……………..………………………………………………… since ………………..……….., is herewith recommended and forwarded for Institute Post Doctoral Fellowship (IPDF) at IIT GUWAHATI in the Department of ………………………………………………………………………………………

1.

This organization does not have any objection for accepting IPDF at IIT Guwahati if selected and the applicant will be deputed/granted leave.

2.

Till the completion of his/her research programme, the applicant will not ordinarily be transferred to another unit or place which may impede his/her work under the scheme. If such a transfer is necessary, IIT Guwahati will be informed within a month of such transfer. We understand that continuing of IPDF will depend on IIT’s decision in this regard, taking into account all relevant factors.

Date:

Signature of the Officer :

Seal of the organization/ Institution

Name and Designation : Postal address of the Organization :